2“Identifying and Treating Pregnant Substance Users” H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAMDirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health Services AdministrationU.S. Department of Health & Human ServicesNational Summit on Substance Exposed Newborns: Collaborative Approaches to a Complex IssueJune 23, 2010 Alexandria, VA
3“As a Nation, we must work together to provide access to effective services that reduce substance abuse and promote healthy living.”August 31, 2009President Barack Obama
4U.S. Department of Health & Human Services “At the Department of Health and Human Services we have a simple mission: protect the health of the American people and provide essential human services, especially for those who are least able to help themselves.”Kathleen SebeliusSecretaryU.S. Department of Health & Human ServicesMay 5, 2009
5Pamela S. Hyde, J.D. Administrator, SAMHSA SAMHSA: Key MessagesBehavioral health is essential to healthPrevention worksTreatment is effectivePeople recover from mental and substance use disordersPamela S. Hyde, J.D. Administrator, SAMHSA
6Substance Abuse and Mental Health Services Administration/CSAT SAMHSA’s Mission:To reduce the impact of substance abuse and mental illness on America’s communitiesCenter for Substance Abuse Treatment (CSAT) Mission:To improve the health of the nation by bringing effective alcohol and drug treatment to every community.666
7SAMHSA’s Role in Improving the Nation’s Health Behavioral health services improve health status and reduce health care and other costs to society. SAMHSA is charged with effectively targeting substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system. Continued improvement in the delivery and financing of prevention, treatment and recovery support services provides a cost effective opportunity to advance and protect the Nation’s health. 777
8Female Past Month Alcohol Use (Aged 12+) 2008 Any Use: %Binge Use*: %Heavy Use*: %Among pregnant women aged 15 to 44, an estimated 10.6% reported current alcohol use, 4.5% reported binge drinking, and 0.8% reported heavy drinking. Binge drinking during the first trimester of pregnancy was reported by 10.4 % of pregnant women aged 15 to 44. This was up from 6.6% reported in 2007.* Binge Alcohol Use is defined as drinking 5 or more drinks on the same occasion on at least 1 day in the past 30 days. Heavy Alcohol Use is defined as drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days; all heavy alcohol users are also binge alcohol users.Source: NSDUH 2008
9Illicit Drug Use among Females Source: SAMHSA, Office of Applied Studies, NSDUH, 2008
10Substance Dependence or Abuse in the Past Year by Gender: 2008 Source: SAMHSA, Office of Applied Studies, NSDUH, 2008, Table 5.4B
11The ChallengeEach year about 105,000 pregnant women need substance abuse treatment.Poverty and limited access to health care contribute to the pervasiveness of substance abuse among pregnant women of low socioeconomic status.Many pregnant women who have substance abuse problems do not seek prenatal care for fear of being reported to law enforcement or social service agencies.Source: Andrulis & Hopkins (2001) and Funai, et al (2003) as cited in Walton-Moss, B. et al. (2009) Health status and birth outcomes among pregnant women in substance abuse treatment. Women’s Health Issues 19:
12Past Month Binge* Alcohol Use: Pregnant and Non-pregnant Women * Binge alcohol use is defined as drinking 5 or more drinks at the same time or within a couple of hours on at least 1 day in the past 30 days.Source: NSDUH
13Past Month Marijuana Use: Pregnant and Non-pregnant Women Source: NSDUH
14Resumption of Substance use among Recent Mothers When compared with women in their third trimester, mothers with children under 3 months old in the household had much higher rates of:alcohol use (6.2% vs. 31.9%),binge alcohol use (1% vs. 10%),cigarette use (13.9% vs. 20.4%) andmarijuana use (1.4% vs. 3.8%)The increase in rates of substance use among parenting women tended to level off as the age of the youngest child increased.Source: NSDUH
15Pregnant Women and Admission to Treatment According to the Treatment Episode Data Set (TEDS), approximately 4% of women reporting for substance abuse treatment are pregnant at the time of admission.On average, 43% had no prior treatment episodes, 24% had 1 prior admission, 13% had 2, 11% had 3 or 4 prior admissions and 9% had 5 or more.In 2008, 32.9% of pregnant women admitted to treatment were referred by the court or criminal justice system.This percentage has been steadily rising since 1992, when it was 20.7%.Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated,
16Primary Substance at Time of Admission – Pregnant Women Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated,
17Methadone-planned Treatment for Pregnant Women Admitted to Treatment Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated,
18Age at Admission to Treatment: Pregnant Women Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated,
19Treating Pregnant Substance Abusers – Barriers Although there are many barriers felt by women who seek treatment for substance use, those faced by pregnant women can be even more serious. Among them:Guilt and shame brought about by societal attitudes toward a pregnant woman’s substance use that may be less understanding and more judgmental.The difficulty of navigating around a drug-using boyfriend/partner/environment upon which the woman may be dependent financially and emotionally.Stigma that results from negative reactions from the treatment community itself.The perceived threat of losing child custody.Source: Shannon, L. & Walker, R. (2008) Increasing the recognition of barriers for pregnant substance users seeking treatment. [Commentary] Substance Use & Misuse. 43:
20Gender-Informed CareHealth professionals need to be sensitive to the unique challenges faced by women who enter treatment, and be prepared to address them as part of their treatment program, including:Trauma (past and present)The importance of relationships (healthy and unhealthy)The challenges faced by the increased number of female veterans returning from Iraq and AfghanistanThe treatment needs of females in the criminal justice system. (Although more men go to prison, the number of women entering prison is growing at a faster rate.)
21The Impact of Relationships on Female Substance Abuse Relationships play an important role in the initiation of substance use among women.For women, initiation of substance use typically begins after an introduction of the substance by a significant relationship such as a boyfriend, partner, or spouse.Some women continue using alcohol and illicit drugs to have an activity in common with their partners or to maintain the relationships. The man often supplies drugs, and the woman becomes dependent on him for drugs.Source: TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women: Chapter 2: Patterns of Use: From Initiation to Treatment
22Treating Pregnant Substance Abusers – The Impact of Interdisciplinary Programs Traditionally, pregnant women with substance abuse had to attend a treatment program for their substance use disorder and a separate medical clinic for their prenatal care.Many times, these women would delay or totally avoid prenatal care while in treatment.Interdisciplinary programs that simultaneously provide prenatal care and substance abuse treatment result in significantly higher infant birthweights or longer pregnancy duration among participating women compared to those who did not participate.
23SAMHSA’s Pregnant and Post-Partum Women (PPW) Program SAMHSA’s Pregnant and Post-Partum Women (PPW) program recognizes the importance of an interdisciplinary – or holistic – treatment approach for pregnant and postpartum women (postpartum refers to the period after childbirth up to 12 months) who suffer from alcohol and other drug problems, and their minor children impacted by perinatal and environmental effects of maternal substance use and abuse.The treatment services offered in the PPW program must be coupled with access to primary health, mental health and social services.PPW is a family-centered treatment approach that builds on the strength and resources of the entire family, supports sustained recovery for individual family members, and improves overall family functioning.
24Pregnant and Postpartum Women (PPW) Program The PPW program has proven successful in helping to reach those in need of substance abuse services by:Providing comprehensive services to women during pregnancy significantly improves the lives of women, children, and their families.In 1992, in accordance with section 508 of the Public Health Service Act, SAMHSA developed a gender and culturally specific residential treatment program for pregnant and postpartum women.24
25PPW: Program Purpose & Population of Focus To expand availability of sustainable, comprehensive, quality residential treatment, recovery support, and family services for pregnant and postpartum women and their minor children impacted by perinatal and environmental effects of substance abuse.Preserve and support the family unit by including fathers of the children, partners of the women, and other extended family members in the treatment program.
26PPW: OutcomesThe PPW program has served 4,752 clients – 51.6% of whom were pregnant at intake.Of Clients who reported…At Intake6-Month Follow-upDifferenceNo substance use47.5%90.9% %Being employed9.2%22.4% 143.5%No arrests84.9%97.7% %Being socially connected93.6%96.3% %Source: SAIS data 2002 – 6/4/10
27PPW: Risk Behavior Outcomes Of Clients who reported…At Intake6-Month Follow-upDifferenceUsing Injection Drugs8.6%1.7% 79.7%Unprotected sexual contact88.7%66.9% 24.6%Unprotected sexual contact with IDU8.3%4.2% 50.0%Unprotected sexual contact with indiv. High on some substance27.1%9.4%65.4%Source: SAIS data 2002 – 6/4/10
28PPW: Mental Health Outcomes Of Clients who experienced…At Intake6-Month Follow-upDifferenceSerious depression52.0%33.1% 36.3%Serious anxiety or tension53.5%39.8% 25.6%Hallucinations3.1%1.7% 45.2%Trouble understanding, concentrating or remembering38.1%26.9%29.4%Trouble controlling violent behavior10.2%5.5%46.1%Attempted suicide1.4%0.3% 78.6%Source: SAIS data 2002 – 6/4/10
29The National Center on Substance Abuse and Child Welfare (NCSACW) The NCSACW is a joint effort between CSAT and the Administration on Children, Youth and FamiliesThe web site provides links to:Technical assistance,Tutorials and training, andInformation about conferences.An average of 500 people visit the web site each day – a total of nearly 42,000 documents were downloaded during the first quarter of FY 09.
30Treatment Improvement Protocols (TIPs) TIPs are best-practice guidelines for the treatment of substance abuse based on the experience and knowledge of clinical, research, and administrative experts. TIPs specific to treating women include:TIP 5 Improving Treatment for Drug-Exposed InfantsTIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women
31TIP 5: Improving Treatment for Drug-Exposed Infants Primary focus of this TIP is the in utero exposure of infants to illicit drugs.In utero exposure to cocaine and opiates, especially heroin, is highlighted, and there is a brief discussion of methadone.In addition, this TIP highlights medical and psychosocial services for drug-exposed infants up to 18 months of age and their families.Concerns regarding older toddlers and children are also mentioned.
32Women’s Services Network CSAT has developed a Network of State Women’s Services CoordinatorsThe WSN has become a subcommittee of NASADAD’s National Treatment NetworkThe “Guidance to States: Treatment Standards for Women with Substance Use Disorders,” was released at the NASADAD National meeting in June 2008.
33Online ResourcesFamily-Centered Treatment for Women with Substance use Disorders – History, Key Elements and ChallengesA monograph introduces the concepts & evolution of family-centered treatment approach – including key principles, challenges, and solutions.Funding Family-Centered Treatment for Women with Substance Use DisordersCompanion to the Family-Centered Treatment monograph– helps treatment providers and State substance abuse agencies to identify & access potential funding sources.